I have a typical story, new grad working in LTC after a short orientation. Shift is 10p to 6:30a (reality is more like 9:00p to 8:00a), alone with two aides - some good, some not so much. Of the four aides I have worked with, the two I was told were "great" scare me the most.
My anxiety level is tremendous. It seems like I am finding out in a roundabout way of what to do or even more importantly what NOT to do. Example. Second shift on my own after orientation, pt had 2300 Carafate. No carafate to be found anywhere. Swing nurse who was there late charting first told me "get one from another pts card". That felt wrong (and no other pt was getting it anyway), so I asked what my other options were and she said to call the pharmacy. I did, they said it would be delivered next day. Gave the other 2300 meds to the pt, who laughed and said this has happened before and no big deal. I went back to ask the swing nurse what else to do and she had left.
I later circled it on the MAR and noted, "med not available, pharm called pt aware no adverse effects noted"
Now a week later I get written up and was told that you NEVER say a med is unavailable (even though it WAS unavailable!!!) and I did not call or fax the MD. I now understand I should have notified the MD about the carafate and I take responsibility for that but I am wondering what else I am missing or doing wrong trying to muddle through this by myself? Information at this facility is conflicting at best and I am not entirely sure what to ask.
Question. What are common LTC rules and procedures that I should know about and be following? I need this job for the moment for experience and paycheck that my family needs and just want to make it without getting into more trouble and it possibly being worse than this carafate thing.
Specializes in LTC/Rehab,Med/Surg, OB/GYN, Ortho, Neuro.
While a little off topic, I've seen "previous shift not reordering med in time" posted a few times. What ever happens to the pharmacy when you've ordered it, got the confirmation faxes and talked to the pharmacist to let them know that you were faxing a new order, and you STILL didn't receive the med for 2 days.
We need to borrow. Because you can't futz around and get orders to hold coumadin because you don't have the pack in for that patient from pharmacy.
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Now to give to speak on this more with my own experience.
A large portion of the IV meds we give are based on weight, the aminoglycosides. We cannot dose the IV meds in the facility since they are dosed by weight. When the troughs indicate a need to change dosing we continue with the current therapy until the new dose arrives.
Unless the trough is critically high which we would hold and draw daily until within range of course.
I have personally spoken to the practitioners about some of the sliding scale meds and let them know there may be a delay in the change of therapy, we have to wait for the pharm to dose and they understand this. LTC is not acute care and we do not have an inhouse pharm. Usually we receive orders that say, "Change dose to xxx amount, continue current therapy until new dose available."
It really is that easy and it really is that simple.
While a little off topic, I've seen "previous shift not reordering med in time" posted a few times. What ever happens to the pharmacy when you've ordered it, got the confirmation faxes and talked to the pharmacist to let them know that you were faxing a new order, and you STILL didn't receive the med for 2 days.
I would make copies of everything and notify the DON, we have fired a pharmacy for this and our current pharmacy fired their old transport company for "losing" meds... too bad one of the other pharmacies is still using them, ugh.
By contract our pharm has 4 hours to get us a new order med, 12hrs to get us a routine ordered med. If they are not complying to this it needs to be documented and reported. Pharmacies report to the DOH like LTCs do too.
There are always those troubling insurance issues or national recalls that seem to hamper things, notify the MD. Its like when the MD orders Protonix, we laugh at them and tell them there is no way in God's green earth the insurance will pay for that and our facility certainly will not, change it or DC it.
You guys can still have a narc e-box? Ours was taken away earlier this year "d/t the new FDA rules"
DEA rules you mean right?
The way we maintain our narc box is that it is technically property of the pharmacy, just stored inhouse. We have to send a signed order and call the C2 dept of the pharm along with fax a form to recieve oral and written permission to withdrawl the specified med.
PITA if you ask me but better than not having anything.
Specializes in Gerontology, Med surg, Home Health.
Wow...some people must work in the perfect world! Most of us do not. We have constant problems with our pharmacy..so much so that we are looking for a new one,but that process is slow and cumbersome.
If the med isn't available, it isn't available. You can't lie on the MAR and say the patient refused, technically you can't borrow and how many docs do you think want to be called because someone is going to miss something as unimportant as Carafate?
The DPH isn't going to know or care if someone misses one dose...it's really about the process...and what you did to correct the problem.
As for all the different sliding scales Asystole proposes....MOST DPH surveyors and practitioners in this state DO NOT like them...with the exception of insulin.
Interesting...I work in LTC in a rural area. Our pharmacy closes at 5 on Saturday and opens again Monday morning at 9. When the nurse forgets to do the Friday med order, or meds don't come for whatever reason, meds run out. I am tasked with writing our new policy since I don't believe in borrowing. If a nurse is too busy to reorder meds, what is the chance that she will remember who she borrowed from to return the med when it comes in? We can't get our pharmacy to do an emergency med box (too expensive and the meds will expire.) Other issue on the same vein...some nurses in our facility try to keep meds when a resident dies for "extras." This is also illegal and will win huge survey points. I worked with our pharmacist to now have labels for our facility purchased meds for residents on medicare who die or have med DC'd. It reads, "This medication purchased by facility and may be used as backup when no longer needed by this resident." It is given that the new resident must have a written order for this med..and that this is temporary until the meds are received from the pharmacy. This allows up so keep the meds on hand for those emergency situations. I have charted NS= No Stock when meds are not on hand and recommend that for the new nurses. (I am not trying to start a fight, but need for the problem to be addressed instead of continuing the bad habits. Maybe the DON or admin does not know it is a problem.) We get meds for some residents from IHS (Indian Health Services) and they often take up to a week when a new order is called in.
Specializes in PACU, CARDIAC ICU, TRAUMA, SICU, LTC.
I am unsure of what you are saying.
Are you saying if you recieved a high INR you would still administer a dose of coumadin?
I would hope you would have standing orders for a sliding scale. Usually we are given a range, if in the range continue, if out of range by x-xx amount increase or decrease dose by x amount, if outside given range, ie critical range repeat INR with iSTAT, hold dose, and contact practitioner.
Again we keep an E-kit managed by pharm with various doses of coumadin to allow various dosing changes.
There are no standing orders for Coumadin in the facility where I work. A medication such as Coumadin is considered a critical med, and all PT/INR results must be reported to the resident's physician, without exception. There are residents who may be on antibiotics, as well as numerous other medications that prolong the PT/INR, necessitating an adjustment in the Coumadin dose. Another issue; although diet is a factor in anticoagulation therapy, dietary services do not have the resources to individualize diets to accommodate a resident's anticoagulation therapy. It is just not feasible.
As for utilizing an iSTAT to repeat abnormals, you must work in an awesome LTC facility. I have never seen one in the numerous LTC facilities where I have worked. We are grateful to have our glucometers updated to newer models! Does your facility have a centrifuge as well?? Just curious...
Specializes in PACU, CARDIAC ICU, TRAUMA, SICU, LTC.
This has been the most common problem in the several LTC facilites where I have worked. Some of the LTC facilities were privately owned, others owned by various corporations. That being said, the privately owned facilities utilized the "MOM and POP" pharmacies that were pleasant to work with, and very willing to "make the system work." These pharmacies depended on the contracts they had with the privately owned LTC facilities (as well as business with their individual customers) for their survival. Pharmacies that are owned by corporations have contracts with a number of LTC facilities. These pharmacies have many employees, and are not customer service oriented, IMO. Each time I have made a call to said pharmacy, I speak to a different pharmacy tech, and have to repeatedly ask: "why do I not have the medication, when it was ordered two days ago?" Frustrating is an understatement. My co-workers and I have repeatedly made TPTB aware of this never ending issue. Despite the DON addressing this issue with a pharmacy representative (assigned to the facility) on a regular basis, the issue(s) continue.
It never occurred to me to contact the Corporate Compliance officer with regard to this issue; what a great .
Instead of , this may be a step in the right direction.
"Asystole," thank you for your comment regarding the order to have the physician state: "Begin the medications when available from the pharmacy." This order is an easy solution to circumvent a state citation for writing "NA." However, if a newly admitted resident has not received a medication that is considered critical for a fragile cardiac problem (for example), this becomes a dilemma. Do I "borrow" the medication, or just wait for the pharmacy to "make their run?" What do I do if no other resident takes a certain medication (such as Pacerone, for example)? Requesting the pharmacy to deliver a medication "stat" equates to a wait time of up to four hours for the medication to be delivered! A back up E Box is not workable for this type of issue; this would require a back up med cart to store the numerous, specific medications prescribed for residents. Routine meds (Colace, MVI, etc..) are stock, and would not be included on the back-up cart. Many of the medications have short expiration dates; no corporation would view a back up med cart as "financially sound." What is optimum for residents is secondary, despite the corporation stating "residents are our priority." Unless you have been living under a rock, we all know this is a bunch of "bunk." Whose responsibility would it be to routinely check the back up med cart? In all probability, it would be assigned to an already overburdened nurse; "just" another task that takes away time to actually care for the residents. Quality of nursing care spirals downward once again.
To all nurses who work in facilities that have solved this conundrum, you and the residents/patients/clients are fortunate.
Suesquatch," thanks. "Zergasaurus," you are an astute new grad.
Enough said. Thanks to all for giving me the opportunity to post my lengthy .
It's definitely a catch-22. In a perfect world, meds can always be available, those in charge of ordering meds NEVER make a mistake, and the pharmacy is available 24/7. LTC is an entity of it's own. We are governed so rigidly, second only behind the Nuclear program.
To have a medication unavailable may be reason for a medication error, but that needs to go back to the one who ommitted ordering or reordering the med. However, writing that it is unavailable will get a citation. A write up for writing that, however, is a little overboard. Orientation, even on a slower shift, should never be considered complete with less than a week's worth of supervision. It's unfair for nurses to get thrown on the floor, expected to figure out all the rules and regulations on their own and be expected to stick around. Again, though, nursing is seldom performed in a perfect world.
she is working in the midnight shift so she must have 35+ patients. if all those patients are out of meds, which are very common in ltc we have to call the doctor each and every time? that is very unrealistic. we can call the pharmacy and tell them to stat deliver the medication, which takes about 3-4 hours but most of time, it takes more than 4 hours for them to deliver. i would just circle it and write in the back of the mar, called pharmacy to deliver "stat"
As for utilizing an iSTAT to repeat abnormals, you must work in an awesome LTC facility. I have never seen one in the numerous LTC facilities where I have worked. We are grateful to have our glucometers updated to newer models! Does your facility have a centrifuge as well?? Just curious...
lol
Yes, actually we do have a centrifuge and a Urysis machine too but the iStat does not require spun blood...
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, this may be a step in the right direction.
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jnrsmommy
300 Posts
While a little off topic, I've seen "previous shift not reordering med in time" posted a few times. What ever happens to the pharmacy when you've ordered it, got the confirmation faxes and talked to the pharmacist to let them know that you were faxing a new order, and you STILL didn't receive the med for 2 days.